RINCIAN KEWENANGAN KLINIS (CLINICAL PRIVILEGE)

DOKTER SPESIALIS BEDAH DIGESTIF

Bagian I. Dokter Pemohon
Spesialisasi: Tanda tangan:
Nama Dokter:
BEDAH
DIGESTIF
Saya menyatakan bahwa saya kompeten untuk menangani kasus-kasus yang saya minta di bidang spesialisasi
saya, termasuk melayani konsultasi dari dokter-dokter lain.
Saya juga menyatakan kompeten untuk melakukan prosedur teknis seperti yang tercantum di bawah ini
sebagai bagian dari kewenangan klinis (clinical privilege) berdasarkan status kesehatan saat ini, pendidikan,
dan/atau pelatihan yang telah saya jalani, serta pengalaman yang saya miliki.

SERTIFIKASI
Universitas : Tanggal:

Pelatihan bersertifikat: Tanggal: Institusi:

SURAT TANDA REGISTRASI KONSIL KEDOKTERAN

Spesialisasi: BEDAH DIGESTIF Berlaku hingga tanggal:
PETUNJUK
Kode untuk Dokter: Kode untuk Komite Medik:
1. Kompeten sepenuhnya 4.Disetujui berwenang penuh
2. Memerlukan supervisi, membentuk tim 3.Disetujui di bawah supervisi, membentuk tim
3. Tidak dimintakan kewenangannya 2.Tidak disetujui karena bukan kompetensinya
karena di luar kompetensi 1.Tidak disetujui karena fasilitas tidak tersedia
4. Tidak dimintakan kewenangannya
karena fasilitas tidak tersedia

Clinical Privilege
No Keterangan Diminta Rekomendasi
Oesophageal Surgery
1. Oesophageal, gastic interposition
2. Oesophagectomy, colonic interposition
3. Oesophagectomy , free jejunal graft
4. Heller procedur ( Oesophageal myotomy ), Oesophageal ( Retlu / Motility )
5. Fundoplication
6. Para Oesophageal Hernia Repair
7. Epiphrenic diverticulectomy
8. Oesophageal myotomy + fundoplasty
9. Zenker’s diverticulectomy (open) gastric surgery
10. Total gastrectomy ( D1 Node dissection)
11. Total gastrectomy ( D2 Node dissection)
12. Proximal gastrectomy ( D1 Node dissection)
13. Proximal gastrectomy ( D2 Node dissection)
14. Gastic tumor, local excision
Laparoskopi
15. Oesophagectomy
16. Gastrectomy
17. Fundoplication
18. Oesophageal myotomy + fundoplasty endoscopy
19. Diagnostic upper GI endoscopy
20. Endoscopy with biopsy
21. Therapeutic upper GI endoscopy
22. Bariatric Surgery and other
23. Gastic band ( laparoskopik)
24. Gastic band ( reversion)
25. Tube gastrectomy ( laparoscopic or open)
26. Roux en Y Gastric Bypass (laparoskopik)
27. Roux en Y Gastric Bypass (open)
28. Roux en Y Gastric Bypass (revisional)
29. Splenectomy
30. Jejunostomy / Gastrostostomy Adjunctive Thoracic Operation
31. Thoracoscopy
32. Thoracotomy for gut interposition
33. Conventional right thoracotomy
34. Colorectal
35. Procedurs for Hemorrhoids
36. Excisional haemorrhoidectomy, open or closed and variant
37. Stappled haemorrhoiopexy (PPH) Anal abcess / Fistula
38. Incission and drainage of abcess
39. Anal fistulotomy or fistulectomy
40. Seton treatment of fistula
41. Endorectal / endoanal flap repair of fistula
42. Repair of rectovaginal fistula (other than flap repair)
43. Other proctological procedur
44. Lateral internal sphincterotomy
45. Injection of Botulinum toxin to anal sphincter
46. Excision perianal lession (skintag, hematoma, viral warts, etc)
47. Excision / lay open / flap repair Pilonidal sinus disease
48. Excision lexteriorisation hidradenitis suppurativa
49. Transanal procedures
50. Transanal excision of tumour
51. Transanal endoscopic microsurgery ( TEM )
52. Anoplasty for stricture or ectropion
53. Transanal repair of rectocoel
54. Stapled transanal rectal resection (STARR)
55. Surgical procedures for incontinence
56. Sphincter repair
57. Graciloplasty
58. Sacral nerve stimulation insertion
 59. Artificial bowel sphincter
60. Prolapse Procedures
61. Perineal repair of rectal prolapse ( Delorme, Altemeier)
62. Transabdominal resection or fixation of rectal prolapse
63. Colonoscopy / flexible sigmoidescopy
64. Diagnostic colonoscopy
65. Colonoscopy and sigmoidescopy polipectomy
66. Colonoscopic decompression of volvulus or pseudoobstruction
67. Colonoscopic dilatation and or metal stent insertion
Colonoscopic endomucosal resection of tumor
68. Segmental colonic or ileo – colic resection
69. Ileocolic resection
70. Right hemicolectomy
71. Transverse colectomy
72. Wedge colon resection
73. Left hemi colectomy
74. Sigmoid colectomy
75. Hartmann’s resection
76. Anterior resection
77. Anterior resection of rectum for benign and neoplastic disease
78. Rectal resection as part of abdomino perineal resection of rectum
79. Perineal rectal resection
80. As part of abdomino perineal resection
81. Rectal resection as part of protectomy for inflammatory bowel disease
82. Total colectomy
83. Whole of abdomino colon, with or without anastomosis
84. Axcludes colectomy as part of ileo-anal pouch procedure
Rectal resection with colo-ileoanal anastomosis
85. Low anterior resection with colo-anal anastomosis
86. Hand sewn to anal canal +/- colonic pouch
87. Stapled to anal canal +/- colonic pouch
88. Rectal resection +/- total colectomy with ileo pouch -anal anastomosis
89. Stoma procedures
90. Creation, reversion, or closure of colostomy
91. Creation, reversion, or closure of ileostomy
92. Laparoscopic procedures
93. Colectomy
94. Rectal resection
95. Rectal prolapse
Tracheostomy
96. Cricothiroidostomy ( needle / surgical)
97. Temporary / percutant
98. Permanent
99. Hepatopancreatico Billiary
100. Liver procedures
101. Wedge excision or segmentectomy
102. Partial
103. Total
104. Right hepatectomy
105. Left lateral hepatectomy ( segmen 2,3,4)
106. Left hepatectomy ( segmen 2,3)
107. Unroofting liver cyst open laparoscopic
108. Metastatectomy non anatomical resection
109. Ablative treatment (eg RFA) for liver tumour
110. Laparoscopic hepatectomy
111. Liver transplantation
112. Gallbladder surgery
113. Open Choleccystectomy
114. Open Choleccystectomy + IOC
115. Open Choleccystectomy + CBD exploration
116. Laparoscopic Choleccystectomy
117. Laparoscopic Choleccystectomy + CBD exploration
118. Choledocoscopy
119. Transduodenal sphincteroplasty
120. Bilio enteric bypass
121. Resection of choledocal cyst
122. Pancreas and duodenum
123. Transduodenal resection
124. Pancreatic duct sphincteroplasty
125. Pancreoticoduodenectomy
126. Retroperitoneal node dissection
127. Distal pancreatectomy
128. Central pancreatectomy
129. Enucleation of pancreatic endocrine tumour
130. Total pancreatectomy
131. Duodenal preserving pancreatectomy ( Bergers)
132. Freys procedures
133. Pancreaticojejunostomy
134. Pseudocyst gastrostomy / Enterostomy
135. External drainage pseudocyst
136. Pancreatic necrosectomy (open / percutaneus)
137. Local excision duodenal tumour (partial)
138. Duodenal exclusion procedures
139. Pancreatic duct sphincteroplasty
140. Laparoscopic pancreatectomy

Dokter Pemohon :

Tanda Tangan Dokter Pemohon Tanggal :

Bagian II. Komite Medik/Sub-Komite Kredensial

 Tanggal :
Disetujui Disetujui dengan Catatan Tidak Disetujui

Catatan :
Menyetujui / tidak menyetujui Rincian Kewenangan Klinis
Merekomendasikan / tidak perekrutan kepada Direktur
Merekomendasikan / tidak penerbitan Surat Tidak Keberatan Praktek untuk
mengurus SIP
Merekomendasikan / tidak untuk penerbitan Surat Penugasan Klinik

Ketua Komite Medik Mitra Bestari Ketua Sub-Komite Kredensial

dr. Sedyo Wahyudi, Sp.A dr. Sedyo Wahyudi, Sp.A